This is a top 10 list encompassing my approach to this difficult situation:
1. Empty the Stomach
Place a salem sump and suck out all of the stomach contents.
Varices are not a contraindication (see: Digest Dis 1973;18(12):1032 and Anesth Analg 1988;67:283)
Administer Metoclopramide 10 mg IVSS
2. Intubate the Patient with HOB at 45°
Semi-Fowler’s position will keep the gastric contents from moving up the esophagus
3. Preoxygenate like mad
You do not want to bag these patients, give yourself a preox cushion
4. Intubation Meds
Use a sedative that is BP stable, use reduced doses.
These patients NEED paralytics. You need to optimize first pass success. Paralytic agents actually increase the lower esophageal sphincter tone (Br J Anaesth 1984;56:37).
5. Gather your equipment to optimize first pass
Use fiberoptic laryngoscopy if you have it (e.g. Glidescope)
At the bedside, have a bougie, an LMA, a meconium aspirator (more below), and 2 suction set-ups
Wear eye protection!
6. If you need to bag after a failed attempt…
Bag gently and slowly (10 times a minute)
Consider placing an LMA if you need to bag.
7. If the patient vomits: Trendelenberg
This potentially keeps the emesis out of the lungs
8. Meconium Aspirator
If the normal suction is too slow, attach the meconium aspirator to your ET tube and the suction tube
9. No ABX for Aspiration
Aspiration in the initial phases is a chemical pneumonitis, not a bacterial pneumonia
See Marik’s article (NEJM 2001;344(9):665)
10. SIRS
Expect a sepsis-like syndrome from the aspiration. This folks may need pressors and tons of additional fluid
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Hi, my name is Scott Weingart. 
{ 6 comments… read them below or add one }
great summary scott. additional thought: although you want to not bag, if you must bag, you want to minimize the amount of air transmitted to the stomach. So abort your laryngoscopy attempts earlier so you’re more likely to bag slowly, gently, and, even better – through an LMA.
Great checklist for the next UGIB intubation, Scott.
As I watched an oropharynx fill with coffee grounds a couple months ago, I was reminded of that really large bore perforated suction catheter on display at an ACEP SA past. Couldn’t find it just now, after doing a quick search online, but a larger bore catheter and tubing would go along well with the meconium aspirator.
I would add that this is a time that you want to have a blind technique ready like the Intubating LMA… although a bougie is technically a blind technique ILMA, would be better… (saved me the last time i saw a mouth full of blood despite 2 yankauers)
Taku,
Absolutely! I had LMA in number 6, but an ILMA would be even better if you have them.
Scott
Scott, I just had a woman with right sided lung CA who developed MASSIVE hemoptysis…actually was just pouring out blood from lungs. She quickly went into respiratory arrest then cardiac arrest. We suctioned 500 mL of blood from her mouth and airway in the first 3 minutes. I called anesthesia (first time I ever thought I wouldn’t be able to intubate someone), couldn’t find a meconium aspirator, but anesthesia intubated anyway, though we couldn’t confirm due to amount of blood. Then of course we couldn’t ventilate her. She died, and I think it was 1. from respiratory then cardiac arrest and no ventilation or 2. bled to death.
What I was wondering was if you had any suggestions of handling this? I’ve heard of single sided bronchus intubation but neither anesthesia nor I knew how to do it. Any suggestions, or was she doomed from the beginning? Thanks, love your podcast and learn something every episode.
I have said before… Love your podcast. So yesterday I just had a GI bleeder that started crashing, but was able to stabilize and thankfully didn’t have to intubate.
Now in hindsight I am here reviewing the “what if’s” and googling “Intubate the GI Bleeder”, and the first thing that pops up on google is this podcast, which it turns out I have alreaded downloaded onto my iPhone (along with all your podcasts), but hadn’t yet listened to this one. So, thanks again for this (and every) posting, please keep them coming.
This brings me to my question: Any chance you can do a top to bottom review of the ER variceal GI Bleed management (beyond the airway, which you have covered)? Would love to see your algorithm and rational with regards to octreotide, FFP, Pantoloc, etc…